Basic Information
| Provider Information | |||||||||
| NPI: | 1265096101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELTAGUNDE | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1270 AVIGNON DR | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953489547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093889903 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3940 SANDPIPER AVE | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953408372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666824842 | ||||||||
| FaxNumber: | 2093814109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2019 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP95011295 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.